Interviewee

Dr Kristian Pollock, Senior Research Fellow, School of Nursing, Nottingham University, UK

Article

Pollock, K. (2007) Maintaining face in the presentation of depression: constraining the therapeutic potential of the consultation. Health: An Interdisciplinary Journal for the Social Study of Health, Ilness and Medicine, 11(2): 163-180.

Summary

Michael Bouwman talks with Dr Kristian Pollock about her study on maintaining face in the presentation of depression in medical encounters. Kristian and Michael talk about the tension between the benefits of saving face verses the benefits of appropriate diagnosis and treatment. They also discuss the qualitative research process adopted in Kristian's study, focusing on how the findings on 'face' emerged from the data analysis.

Transcript

Michael Bouwman: Introducing Dr. Kristian Pollock, Senior Research Fellow in the School of Nursing at Nottingham University, United Kingdom. We are here to discuss Kristian's research and subsequent article, 'Maintaining Face in the Presentation of Depression: Constraining the Therapeutic Potential of the Consultation.' Firstly, congratulations on your work Kristian, we believe your work has bought implications across health care. Would you like to start by providing a background to the problem by talking about the reasons why depression is frequently undetected and poorly treated?

Kristian Pollock: The purpose of the research was to explore how patients and doctors communicate about emotional distress in primary care consultations, how diagnosis of depression is reached and how acceptable and helpful this is to patients and how they experience subsequent treatment with anti-depressants. There's a considerable body of research which suggests that intentionally or otherwise patients frequently don't raise the topic of emotional distress when they consult their general practitioners and doctors by the same token have often been found not to detect the presence of emotional distress in their patients. So we wondered how did it happen that some patients come to be diagnosed suffering from depression while others don't, what the patients expect from the consultation and what are the communicative cues exchanged between doctor and patient which result in the topic of depression being raised or excluded on consideration. And again previous research has shown that patients may not intend to disclose their distress because they don't feel that these are an appropriate topic for the doctors to get involved with or because they feel it would be pointless to express their problems because they don't expect the doctors to be able to help. They may not recognize the extent of the difficulties they're experiencing or they may not regard these experiences as constituting illness and they may consider that it's up to them themselves to cope with their problems, perhaps with family and social support rather than through medical diagnosis and treatment. And this may be a reasonable and appropriate strategy for many people and one of the concerns about misdiagnosis of depression, is that it can be over diagnosed and over treated as well as the contrary and that most episodes of mild to moderate depression can be self-limiting and lacks a resolve on their own accord but there???s also evidence and this applied to most of the patients in our study, that many people consult their doctors because they've run out of resources, they've exhausted all their available sources of help and they just don't know where to turn so they go to their doctor and this was the case as I say, with most of the respondents of the study and if patients themselves fail to disclose the extent to which they're experiencing difficulties then it's obviously going to be difficult for doctors to pick that up and deal with it.

Michael Bouwman: What did your findings reveal about the clinical encounter that helps to understand this situation?

Kristian Pollock: I think our research pointed out just how difficult patients often find telling doctors about their problems and how awkward and uncomfortable they might feel in making decisions to consult the doctor and in the actual interaction in the consultation itself and patients were very concerned with managing the consultation as a social interaction and how the concern to accomplish this successfully could override their ability to communicate their problem. There's a tremendous cultural pressure to maintain composure and self-control in social interaction, not just medical interaction so that saving face of both oneself and others which is originally analyzed by Erving Goffman, is seen to be a basic strategy of maintaining social interaction and this sort of enables the encounter to succeed and it preserves the integrity of all the participants. Because of the intrinsic power differential between doctor and patient and because the experience of illness involves either actual or implied loss of emotional and bodily control, medical consultations are intrinsically face threatening encounters and our respondents often described how in their daily lives they concealed or tried to conceal the extent of the distress even from people closest to them by putting on a front or maintaining face and this mask, this front, they found hard to relinquish even in medical consultations. It was just very difficult for them to overcome this very deeply ingrained etiquette or communicative conventions at the consultations, to be able to drop their mask and reveal the extent of their problem and unless or until they could do this, they couldn't effectively ask for help so we concluded that the social imperative of consultation often worked to undermine its therapeutic potential.

Michael Bouwman: In discussing your findings you speak of the tension between the benefits of saving face versus the benefits of appropriate diagnosis and treatment. Would you like to discuss this tension and the implications to health care practice?

Kristian Pollock: Yeah, I think the tension relates largely to peoples' concern to maintain their self-esteem, their social competence and many people find themselves in a kind a double bind because they felt their sort of integrity was sort of threatened by the difficulty they had and continued to cope without help but it could also be jeopardized by the admission that they needed help. And in particular, by the application of the kind of illness label, the diagnostic label of depression and the acceptance of treatment with anti-depressants. And most people were really quite ambivalent at certain points at least in the process of treatment and recovery and particularly as a sort of consequence of the diagnosis and treatment might only become apparent after sometime. So, people could start treatment without anticipating the future consequences or difficulties that this could pose for them. Uncertainty about their ability to cope without anti-depressants in the future was troubling to some people, they sort of wondered, is it me, is it my medicine that's helping me get through life and some people came to question their need to take anti-depressants and also wondered if they could've get better without them but of course once they've accepted anti-depressants in not having an effect on their perception of themselves and they found it very difficult to voice these concerns to their doctor, especially after treatment started. In the majority of cases, the GP's responded to patients' disclosure, psycho-social distress effectively as a request for help with a recommendation to take anti-depressants so in terms of the implications to health care practice, I think one of the most significant things to emerge from this study is the distance between patient and professional understandings of psycho-social distress and particularly, the role and efficacy of anti-depressants. We found that most of the doctors really didn't have much awareness or understanding of patients' concerns about these and how difficult most people found discussing these concerns. So overall we hope the research will contribute to the ongoing debate about the appropriate prescribing of anti-depressants and the best ways to support patients and especially in the ways that patients find most helpful and constructive rather than perhaps in terms of a rather narrowly defined biomedical model which is still pretty much standard at the moment I think.

Michael Bouwman: Kristian it's been a pleasure, thank-you so much for giving us your time today.

Kristian Pollock: It's a pleasure, thank-you very much.